Recession and high co-pays tied to fewer colonoscopy screenings among people with health insurance

The recent U.S. economic recession was the longest and most severe since World War II. During this period, personal spending on health care grew at the slowest rate in more than 50 years, suggesting that Americans used less health care.

A new study finds that these cut backs were not limited to Americans who lost their health insurance, nor restricted to unnecessary services. Researchers at the University of North Carolina at Chapel Hill schools of medicine and public health found that during the recession, continuously insured Americans underwent fewer screening colonoscopies, a cost-effective, recommended preventive service. The study appears in the March issue of the journal Clinical Gastroenterology and Hepatology.

The investigators estimated that during the recession period, dating from December 2007 to June 2009, roughly one-half million fewer Americans covered by commercial health insurance underwent colonoscopy screening for colorectal cancer than expected based on use in the preceding two years.

These time periods were defined by the National Bureau of Economic Research, the nation’s leading nonprofit economic research organization and official arbiter for dating recessions.

The study of 50- to 64-year-olds also found a strong link between direct out-of-pocket (OOP) costs for this elective procedure and whether or not patients were more likely to get screened as their doctors recommended.

“We found that patients facing high out-of-pocket costs were less likely to undergo colonoscopy at any time point, especially during the recession,” said Spencer D. Dorn, MD, MPH, leader of the study and assistant professor of medicine in the UNC School of Medicine’s Division of Gastroenterology and Hepatology.

“Before the recession, these individuals were less likely to get a screening colonoscopy, but the gap in use between those with high and low out-of-pocket costs was narrowing. When the recession hit full force, the discrepancy in use widened again.”

Low OOP was defined $50 or less; high OOP, $300 or more.The researchers analyzed data from 106 U.S. health plans that fed into the IMS LifeLink Health Plan Claims Database. Dorn noted that this is nationally representative of the commercially insured U.S. population and does not include those served by Medicare or Medicaid.

“These findings reflect the intimate link between socioeconomic factors and health care use,” the authors state. When faced with the stress of economic insecurity, otherwise healthy people who are covered by health insurance “may be unable to afford screening colonoscopy, or may perceive it to be less important than competing demands for limited resources.”

The findings, say the authors, add to the growing evidence that cost sharing is a disincentive for preventive health services. For example, requiring women to pay a $10 to $20 co-pay has been shown to make them less likely to undergo screening mammography.

The new health care reform act has eliminated Medicare and Medicaid copayments and deductible requirements for all federally recommended preventive services, including colorectal cancer screening. The authors suggest that commercial insurers “follow suit” by exploring new ways to reduce patient cost-sharing.

Study co-authors from UNC, in addition to Sandler and Shaheen, are David Wei, research assistant and Joel F. Farley, PhD at the Eshelman School of Pharmacy; and Michael D. Kappelman, MD, MPH, at the School of Medicine. Co-author Nilay D. Shah, PhD, is at Mayo Clinic, in the Division of Health Care Policy and Research.

Sandler and Shaheen also have appointments in the School of Medicine. Shaheen is professor of medicine, and Sandler is Nina C. and John T. Sessions Distinguished Professor of Medicine and chief of the Division of Gastroenterology and Hepatology.

Support from the study came from the National Institutes of Health and the Crohn’s & Colitis Foundation of America.